health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Peritonitis is an inflammation of the peritoneum often caused by infection. Administering antibiotics is crucial to combat the infection. It is important to treat the underlying cause first before focusing on symptom management. Administering analgesics (B) may provide temporary relief but won't address the infection. Applying an ice pack (C) is not appropriate for peritonitis as it won't treat the infection. Performing a laparotomy (D) is a surgical procedure that may be necessary in severe cases but is not the initial nursing action.

Correct Answer: B

Rationale: The correct answer is B: Monitoring serum albumin levels. This is because serum albumin is a protein synthesized by the liver that reflects long-term protein intake and overall nutritional status. Low levels indicate malnutrition or inflammation. Obtaining a dietary history (choice A) is important but may not always reflect the actual nutritional status. Monitoring weight (choice C) is helpful but may not provide a comprehensive view of the client's nutritional status. Providing a meal plan (choice D) is a proactive approach but does not directly assess the client's current nutritional status.

Correct Answer: B

Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. Oxygen administration is the first intervention for shock as it helps improve oxygenation to vital organs. Lack of oxygen can worsen shock. Administering IV fluids (choice B) could be the second step to improve perfusion. Monitoring respiratory rate (choice C) is important but not the first intervention. Administering pain medication (choice D) is not a priority in managing shock.

Correct Answer: C

Rationale: The correct answer is C: Neutropenia. Chemotherapy can suppress bone marrow function, leading to a decrease in neutrophils (a type of white blood cell), causing neutropenia. This increases the risk of infection. Monitoring for signs of infection is crucial in patients receiving chemotherapy to prevent serious complications. Anemia (A) is a common side effect of chemotherapy but is not directly related to infection risk. Hyperkalemia (B) and hypocalcemia (D) are less likely to be immediate complications of chemotherapy compared to neutropenia.